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used by mouth in cooperative patients or by NG tube; the usual recommended dosing is 500 mL/hr in toddlers and L/hr in adolescents and adults GI Decontamination Strategies It should be apparent that no unique approach to GI decontamination of all poisoned patients is optimal in every case Factors to be considered include the expected degree of toxicity from the drug, the physical nature of the drug, the current location of the drug within the body, and the presence of contraindications or alternatives A risk–benefit decision must be made before the institution of any decontamination strategy Given the considerations discussed above, in the patient for whom GI decontamination is appropriate, activated charcoal and WBI are the favored procedures Ipecac-induced emesis is no longer endorsed as home first aid for poisoning nor in the ED setting Gastric lavage still has some role, albeit confined to patients with recent ingestions of extremely toxic and potentially lethal substances, especially when those substances not bind well to charcoal Likewise, patients with truly massive overdoses may benefit from lavage when the charcoal dose given does not achieve the ideal charcoal-to-drug ratio of 10:1 (10 g of charcoal to g of drug) The correct technique for decontamination, regardless of method, requires that the ED provider take steps to prevent aspiration and anatomic trauma Some of the patients in question would have undergone endotracheal intubation during the initial life support phase of management, as detailed previously, or they may be intubated preemptively because of borderline mental status and in anticipation of their ensuing critical course Others may be awake, alert, and cooperative, with normal airway protective reflexes, and thus be given activated charcoal without prior endotracheal intubation The combative, agitated patient poses a dilemma and must be carefully managed on an individual basis An attempt to summarize these considerations is diagrammed in Figure 102.1 Antidotal Therapy Commonly used specific antidotes include dextrose, oxygen, naloxone, and N -acetylcysteine In addition to the above, the antidotes that should be available for immediate administration include sodium bicarbonate (tricyclic antidepressants), sodium nitrite/sodium thiosulfate or hydroxocobalamin (cyanide), atropine and pralidoxime (cholinesterase inhibitors), ethanol or fomepizole (ethylene glycol and methanol), deferoxamine (iron), methylene blue (methemoglobinemic agents), flumazenil (benzodiazepines), pyridoxine (INH and Gyromitra mushrooms), digoxin
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